Abstract

Purpose: Tobacco use continues to be the leading cause of cancer deaths in the U.S. In 2016, the Food and Drug Administration (FDA) announced that it would regulate little cigars and cigarillos (LCCs) and expressed concerns about the risks of dual use of combustible tobacco products. Little cigars and cigarillos (LCCs) are growing in popularity among young people and racial/ethnic groups who experience disproportionately higher rates of tobacco-caused cancers. To better understand the relationships between dual use patterns and nicotine dependence, this study investigated the association between dual use of cigarettes with LCCs and time to first cigarette within 5 minutes of waking in the morning. We hypothesized that dual users of cigarettes and LCCs (either with tobacco or marijuana in the LCC casing) would show increased dependence on nicotine.

Procedures: An online cross-sectional survey administered in 2015 by the GfK Group (formerly Knowledge Networks) was used to collect data on LCC use behaviors among a national probability sample of African American, Hispanic, and White cigarette smokers, 18-44 years of age (n=1018). GfK conducted the survey by recruiting samples from the KnowledgePanel® and opt-in panel sources. The primary independent variable was tobacco use subtype (cigarette-only = reference; cigarette and other tobacco use excluding LCCs; LCCs with tobacco retained in the casing; LCCs with marijuana in the casing (LCC-blunt); or LCC poly use (LLC-tobacco and LCC-blunt). Associations of tobacco use subtype with the primary outcome, time to first cigarette within 5 minutes of waking were tested in multivariable regression models, which adjusted for demographics (e.g., age, gender, race/ethnicity) and other covariates, including the use of menthol cigarettes, smoking frequency, smoking intensity, self-efficacy to quit, other tobacco use, use of marijuana other than blunts, and alcohol use.

Results. In the sample of cigarette smokers, 48.6% were cigarette-only smokers, 13.9% used cigarettes and other form of tobacco not including LCCs, 15.4% used LCC-tobacco, 11.5% used LCC-blunts, and 10.6% were poly users (LCC-tobacco and LCC-blunt users). The majority of African American (57.6%), Hispanic (64.0%), and male (55.2%) cigarette smokers were dual users. In the weighted adjusted regression models, results showed that young adult cigarette smokers who were poly-users were nearly twice as likely to smoke a cigarette within the first 5 minutes of waking compared to cigarette-only users (AOR=1.97, 95% CI=1.03-3.75). Male poly users were more than twice as likely as cigarette-only users to smoke a cigarette within the first 5 minutes of waking (AOR=2.32, 95% CI= 1.04-5.17). Female blunt users were 3 times as likely as cigarette-only users to smoke a cigarette within the first 5 minutes of waking (AOR=3.19, CI=1.45-7.00). African Americans who used LCC-tobacco were less likely than cigarette-only users to smoke a cigarette within the first 5 minutes of waking (AOR=0.17, 95% CI=0.04-0.63). Hispanics who used LCC-tobacco or LCC-blunt were nearly 4 times as likely to smoke a cigarette within the first 5 minutes of waking (AOR=3.99 CI=1.39-11.43; AOR=3.88, CI=1.37-11.01). Among White cigarette smokers, there were no significant differences in time to first cigarette among tobacco use subtypes.

Conclusions. Results showed that dual use behavior is common and that there is differential risk of nicotine dependence by tobacco use subgroup type and by racial/ethnic and gender groups. Marijuana in LCCs may increase addiction to cigarettes for males, females, and Hispanics, but not for African Americans. These data are complex, but point to the need to develop tailored health messages for cigarette-only users and dual users.